Food and symptom chart for (name)…….
Week beginning (write date):
Diet/intervention being followed:
M T W T F S S M T W T F S S M T W T F S S M T W T F S S
Diet/intervention followed 100%?
X or Y
Medications being taken? X or Y
Write a number of behaviours or symptoms to be monitored below:
Score daily total or 0= none/not present, 1= mild/occasional, 2= moderate/frequent, 3= severe/always
Make notes overleaf: Any other factors that may have affected symptoms or behaviours e.g. illness, change in routine, and your
conclusions – do you think the diet or intervention helped?
Ideas for behaviours or symptoms to monitor on chart (these are some ideas for children with ASD):
Social interaction: Being alone; Seeking out the company of others; Paying attention to others; Eye-contact; Smiling
Communication: Vocal communication; Using gestures; Speech; Making repetitive sounds
Bowel habits: Bloating; Wind; Diarrhoea; Constipation; Tummy pain; Number of times bowels opened and stool form
Sleep habits: Number of time woken during night and for how long
Challenging behaviour: Self-injury; Aggression; Head-banging; Resistance to change; Agitation; Inappropriate anxiety or
Designed by Zoe Connor RD October 2006. Downloaded from ww.nutritionnutrition.com